Salvage cystectomy after failure of interstitial radiotherapy and external beam radiotherapy for bladder cancer

OBJECTIVE: To evaluate the long-term results of salvage cystectomy after interstitial radiotherapy (IRT) and external beam radiotherapy (EBRT) for transitional cell carcinoma, and to assess the morbidity and functional results of the different urinary diversions used. PATIENTS AND METHODS: The records of 27 patients treated with salvage cystectomy in one institution between 1988 and 2003 were retrospectively analysed. RESULTS: Salvage cystectomy was used after failure of IRT in 14 or EBRT in 13 patients, with a 3- and 5-year survival probability of 46% (95% confidence interval 26-65) and 33 (11-54)%. The 5-year overall survival after cystectomy was 54% after IRT and 14% after EBRT (P = 0.12). Tumour category, response to radiation, American Society of Anesthesiology score, and complete tumour resection had a significant influence on survival. Five of seven patients with incomplete resection died because of local disease, with a median survival of 5 months. There was clinical understaging after radiotherapy in 41% of patients. Nine patients had an orthotopic neobladder, with complete day- and night-time continence in eight and four, respectively. All patients but one had good voiding function. There were early complications in two and late complications in six patients (for Bricker, seven of 14 and none; for Indiana, none of four and two of four). The duration of hospitalization was not influenced by the type of diversion. Erectile function was maintained in four of six patients after a sexuality-preserving cystectomy and neobladder. CONCLUSIONS: Salvage cystectomy can be performed with acceptable morbidity using any type of urinary diversion. Understaging after radiotherapy is common, but preoperative selection needs improving. A very significant factor for an adverse outcome and death from local tumour recurrence was incomplete resection, suggesting that salvage cystectomy should only be attempted if complete resection is probable.     

Intraoperative radiotherapy for resectable and unresectable pancreatic carcinoma

Eighty patients with pancreatic carcinoma were treated by intraoperative radiotherapy (IORT) with or without surgical resection of the tumor, and the results were compared with those of 111 patients treated by surgery alone. For resectable patients, the radiation dose was 30 Gy and the average field sizes were 8 or 10 cm; for unresectable patients, these values were 20–30 Gy and 6 or 8 cm, respectively. No side effects of IORT were observed. In 49 resectable stage III patients, the IORT group (n=16) had a higher survival rate than the non-IORT group (n=33); i.e., 1-year survival rates of 44.6% vs 23% and 2-year survival rates of 37.2% vs 7.7% after surgery (P<0.05). However, there was no significant difference in survival rate between the IORT group (n=28) and the non-IORT group (n=29) in 57 resectable patients in stage IV. In unresectable patients, the IORT group (n=31) (P<0.05) had a higher survival rate than the non-IORT group (n=38) (P<0.05). The palliative effect of IORT on abdominal or back pain was evaluated in 15 patients who had such symptoms and did not undergo tumor resection. Overall, pain decreased or disappeared in 13 of these patients (87%). Offprint requests to: A. Nakao     

Postmastectomy radiotherapy: Indications and implications

BackgroundAlthough breast conservation surgery, when combined with radiotherapy, has been shown to provide excellent locoregional control for breast cancer, approximately one third of women with breast cancer require mastectomy. Many of these women are offered immediate reconstruction. Postmastectomy radiotherapy (PMRT) is indicated in some cases, but is associated with side-effects, including its impact on the reconstructed breast.ObjectiveTo review the pertinent issues surrounding PMRT, including patient selection for radiotherapy and the effect of radiotherapy on reconstructive decisions.MethodsA literature review was performed using the Medline database.ConclusionsPMRT is indicated in patients who are deemed to have a high risk of loco-regional recurrence. Although PMRT is strongly recommended for patients with four or more positive lymphnodes, other indications for PMRT remain controversial. Immediate reconstruction post mastectomy has been shown to have favorable outcomes. However, PMRT may increase the need for revision surgery post immediate reconstruction. There are few randomized trials looking at these key issues, and the evidence is largely derived from observational retrospective studies. Patients should be carefully counseled before a decision is made to proceed with immediate reconstruction, where there is a high chance that PMRT may be indicated.     

Stereotactic radiotherapy in metastatic breast cancer

The treatment of metastatic breast cancer is largely focused on systemic therapy. However, over the past decades, there has been growing interest in the use of metastasis-directed therapy in selected cases presenting with an oligometastatic phenotype, i.e. low disease burden with a more indolent biology. Identification of the oligometastatic breast cancer population has, so far, proven elusive. Stereotactic radiotherapy offers an effective, non-invasive approach to ablate metastatic disease both in the brain and in extra-cranial settings. The advent of advanced imaging techniques for target definition, along with the ability to achieve highly conformal dose deposition with steep dose fall-off, enable safe implementation of extreme hypofractionated and single fraction regimens with ablative intent. There is growing evidence that radiation-based treatments are more cost-effective when compared to other ablative modalities. This article provides preliminary evidence that metastasis-direct ablation, with advanced radiotherapy techniques, may play an important role in the management of metastatic breast cancer patients, potentially improving clinical outcomes with minimal toxicity. However, prospective randomized controlled trials are needed to further the understanding of the interaction between systemic therapy and ablative irradiation. Additionally, research in genomic and molecular profiling is needed to characterize metastatic breast cancer patients who will most likely benefit from such combined treatment approaches.     

Percutaneous radiotherapy for low-risk prostate cancer: options for 2007

Technical developments of radiotherapy (RT) over the recent years yielded in better conformation to the target volume thus increasing the therapeutic ratio and decreasing side effects. This paper discusses these options for low-risk prostate cancer. There has been evidence from randomized trials, that for low-risk PCA doses >70 Gy are significant better in case of biochemical disease-free survival (bNED). Image-guided radiotherapy (IGRT) has been proven in several studies for reduced safety margins around the prostate target volume. Intensity-modulated radiotherapy (IMRT) allow treatment with higher doses and 5-year results are reported from several studies. Data from several randomized trials about adjuvant RT after radical prostatectomy (RP) have been reported. In two phase-III trials a significant advantage of 20% bNED was demonstrated for doses between 76 and 79 Gy compared with 70 Gy. Using IGRT, the safety margin around the prostate can be reduced for about 30–50%. Doses of >80 Gy can be given safely to the prostate with IMRT and <5% grade-III/IV late side effects. Adjuvant RT for positive margins after RP has been of proven advantage. Three phase-III trials achieved a significant better bNED of 20% for 5 years. The effect of doses >70 Gy have been proven for low-risk PCA. IGRT resulted in reduced safety margins and a decrease of acute and late side effects. The addition of IMRT allowed higher doses to the prostate. Adjuvant RT after RP for positive margins achieved a significant better bNED.     

Salvage radiotherapy following radical prostatectomy

Biochemical relapse will occur in 17–64% of men who undergo radical prostatectomy, and up to a third of men with biochemical relapse will progress to develop metastatic disease and ultimately die of prostate cancer. Postoperative salvage radiotherapy (RT) to the prostatic fossa is well-tolerated and potentially curative treatment and should be considered for all men who have biochemical relapse following prostatectomy. Gleason score <8, prostate-specific antigen (PSA) doubling time >10 months and PSA re-emergence >2 years following surgery predict for a low risk of early metastatic failure, but even men with no favourable prognostic factors may have a long-term durable response to RT and should not be excluded from consideration of treatment on the basis of these factors alone. Positive surgical margin status and a positive anastomotic biopsy do not predict response to RT, and routine biopsy is not recommended. PSA level at time of RT is a strong indicator of durable response to RT. No one PSA cutpoint level appears to be more significant, and early RT is likely more effective than late. Contemporary PSA assays can detect biochemical relapse in the 0.01–0.2 range, and this may provide additional therapeutic advantage if treatment can be given when tumour burden is smallest. There is an urgent need for prospective data from randomised trials to optimally select patients for salvage RT, to determine the optimal time to initiate treatment and to determine the role of adjuvant hormone therapy, and all patients should be considered for entry into ongoing and future clinical trials.     

Principles of cancer treatment by radiotherapy

Radiotherapy (or radiation therapy) uses ionizing radiation to selectively kill cancer cells, especially for solid tumours. Like surgery, it is meant to be a ‘local’ treatment, although its beneficial systemic effects are being discovered. It is most commonly used in addition to surgery (adjuvant, e.g. breast), but its role in the neoadjuvant setting in combination with chemotherapy for some cancers (e.g. rectum) is also established. In early stages of cancer, it can be the definitive treatment, avoiding surgery and enabling organ preservation (e.g. larynx), while in late stages, it can provide excellent palliation (e.g. bone metastasis). Radiotherapy can be delivered at various energy levels (kiloVolts, megaVolts), with various subatomic particles (e.g. electrons, protons, and high-energy electromagnetic radiation). The traditional bulky equipment (e.g. linear accelerator) needs to be housed in an underground bunker and uses complex imaging to improve precision and avoid radiation to normal tissues. Fractionated regimens spanning several days reduce individual doses. Modern techniques using mobile devices (e.g. TARGIT-IORT) can deliver radiotherapy during surgery with the highest precision and immediacy.     

Propofol infusions for radiotherapy

The use of an intravenous propofol infusion as the sole anaesthetic agent for radiotherapy or isotope bone scan in young children is described. Six children received a total of 127 anaesthetics. In one case both ketamine and propofol were used and the recovery patterns compared. The advantages of smooth induction, good airway maintenance in both the supine or prone position, and rapid recovery following procedures of varying duration are discussed.     

放疗在胆囊癌中的研究进展

胆囊癌是一种恶性程度极高的消化道肿瘤,预后差,目前仅根治性手术切除能取得良好的治疗效果。放疗作为肿瘤辅助治疗和姑息性治疗的重要组成部分,已在多种恶性肿瘤的治疗中获得广泛应用,取得一定疗效。本文回顾既往文献,主要从胆囊癌术后放疗、术前新辅助放疗、术中放疗以及胆囊癌姑息性放疗4个方面综述放疗在胆囊癌中的研究进展。     

三维立体定向放射治疗肺癌

目的：探讨立体定向放射治疗肺癌的临床疗效。方法：27例肺癌采用CT定位2mm层厚连续扫描并通过图像重建，计算出临床靶体积(CTV)，计划靶体积(PTV)及受累器官体积的照射量-体积直方图。应用德国Leibinger的立体定向系统和Varian 600c加速器进行治疗。采用中等剂量，每次5Gy～7Gy，每日一次，连续治疗5次～8次。结果：本组27例肺癌在接受立体定向放射治疗过程中无死亡，患一般状况评分采用Karnofsky(KPS)标准。术前KPS评分20～80分，平均59分。术后KPS评分20～100分，平均87分。随访2月～58月，平均26月，按实体瘤疗效标准：完全缓解(CR)：4例；部分缓解(PR)：17例；无变化(NC)：2例；进展(PD)：4例。肿瘤控制有效率85％(23／27)。结论：立体定向放射治疗肺癌近期疗效良好。     

Chemotherapy and radiotherapy for colorectal cancers

Surgery remains the cornerstone of the curative treatment of localized colorectal cancer (CRC), but both radiotherapy and chemotherapy play an important role in the management of these patients to help improve survival. Treatment of locally advanced and metastatic disease often requires multimodality therapy. Advances in both surgical techniques and non-surgical oncology have led to a reduction in the mortality rate over the last 40 years.     

立体定向适形放射治疗危重肝脏肿瘤12例报告

目的　本组报告立体定向适形放射治疗肝脏肿瘤 12例 ,并作临床分析。方法　自 1997年 5月 -2 0 0 1年 10月治疗 12例肝脏肿瘤。肿瘤的临床靶体积 (CTGV)为 0 .6-2 3 2cm3 (平均为 40 .6cm3 )。计划靶体积处方计量是 3 .96-7.0 0Gy(平均为 5 .14Gy)。分 5 -8次照射。结果　治疗过程中无一例死亡。患者一般状况评分 (KPS)评发 ) :治疗前为 2 0 -90分 ( 5 4± 2 5 .9分 ) ,治疗后 3 0 -10 0分( 74± 2 3 .9分 )。随访 1-4年期间 ,按实体瘤标准 :完全缓解 (CR) 3例 ;部分缓解 (PR) 5例 ;无变化(NC) 3例 ;进展 (PD) 1例。肿瘤控制有效率为 91.6%。结论　立体定向适形放射治疗肝脏肿瘤有较好疗效     

新辅助放疗在低位直肠癌中的应用

目的探讨新辅助放疗在低位局部进展期直肠癌中的疗效及其对保肛手术的意义。方法回顾性分析2000~2005年39例行新辅助放疗低位直肠癌病人的临床资料。结果肿瘤距肛缘3~7 cm,平均4.9 cm。放疗后21例(53.8%)排便困难、便血等症状得以改善。腹会阴联合切除14例,低位前切除术13例,Parks术8例,Hartm ann术4例。术后病理显示肿瘤完全消退(CR)3例,肿瘤部分缓解(PR)22例,无效(NR)14例,总有效率为64.1%(25/39)。保肛率为53.8%(21/39),其中放疗有效者(CR PR)保肛率为64%(16/25),无效者为35.7%%(5/14),两者间差异有显著性意义(P<0.01)。结论新辅助放疗对多数直肠癌病人有效,可以使肿瘤缩小、降低分期,并可提高低位直肠癌的保肛率。     

Delayed and localized pemphigus vulgaris after breast cancer radiotherapy

Breast cancer treatment involving ionizing radiation causes characteristic radiation dermatitis in the majority of patients. The DNA damaging effects of radiation can rarely predispose to primary inflammatory dermatoses, such as pemphigus vulgaris. In such cases, the disease presents with all the hallmarks of the primary dermatosis, but the eruption is limited to the field of irradiation and is often amenable to treatment. In contrast, occurrence of generalized pemphigus vulgaris in this setting may mean cancer recurrence. The mechanism by which radiotherapy induces localized disease remains unknown, but there is likely a loss of self‐tolerance which maybe coupled to antigen exposure.     

Intraoperative radiotherapy for pancreatic adenocarcinoma

Intraoperative radiotherapy (IORT) is an innovative treatment approach for cancer of the pancreas. The common causes of treatment failure in pancreatic cancer are regional recurrence and distant metastasis. While at present the benefit of IORT in unresectable pancreatic cancer is still controversial and awaits further prospective trials for its clarification, the experience gathered over a period of 30 years with IORT for pancreatic cancer does suggest that IORT should be part of the adjuvant therapy of surgical resection. A combination with pre- or postoperative external beam radiotherapy and chemotherapy may be beneficial for both resectable and unresectable patients. IORT was shown to be a relatively safe intervention and it notably improved the quality of life of patients with locally advanced pancreatic carcinomas by alleviating their pain. Here, we summarize and discuss the experience reported to date and present our historical analysis of IORT for pancreatic cancer. Received for publication or Sept. 18, 1997; accepted on March 25, 1998     

X线立体定向治疗脑转移瘤疗效分析

目的　探讨影响X线立体定向治疗 (Stereotacticradiotherapy ,SRT)脑转移瘤疗效及并发症的相关因素。　方法　对 77例 ( 15 6个脑转移灶 )进行回顾性分析。 142个脑转移灶采用X线立体定向治疗联合常规全脑放疗 ,14个脑转移灶单纯采用X线立体定向治疗。　结果　多因素分析脑转移瘤X线立体定向治疗有效率和并发症率与转移灶体积及周边剂量有关。转移灶体积≤ 4ml的有效率为 81 0 % ( 85 / 10 5 ) ,明显高于转移灶体积 >4ml有效率的 45 1% ( 2 3/ 5 1) ( χ2 =2 0 7,P <0 0 0 1) ,并发症率由 3 8% ( 4/ 10 5 )上升至 2 9 4 % ( 15 / 5 1) ( χ2 =2 1,P <0 0 0 1)。靶周剂量 (ED2Gy) >6 8Gy的有效率为 81 3% ( 6 5 / 80 ) ,显著高于ED2Gy≤ 6 8Gy的 5 6 6 % ( 43/ 76 ) ( χ2 =11 1,P <0 0 0 1) ,并发症率由 18 8% ( 15 / 80 )下降至 5 3 % ( 4/ 76 ) ( χ2 =6 6 ,P <0 0 5 )。　结论　脑转移瘤体积及靶周剂量是影响SRT疗效和并发症的两个最重要因素。